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Evidence Based Approach to Cesarean Delivery in the Obese Gravida

Evidence Based Approach to Cesarean Delivery in the Obese Gravida. Objectives. Name 3 comorbidities associated with obesity in the general population and 2 additional comorbidities associated with obesity in the pregnant population.

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Evidence Based Approach to Cesarean Delivery in the Obese Gravida

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  1. Evidence Based Approach to Cesarean Delivery in the Obese Gravida

  2. Objectives • Name 3 comorbidities associated with obesity in the general population and 2 additional comorbidities associated with obesity in the pregnant population. • Name 3 measures that can be taken preoperatively to decrease morbidity during a C-Section • Name 2 measure that can be taken intraoperatively to decrease morbidity during a C-Section

  3. Definition of Obesity • Definition BMI (kg/m2) Obesity Class • Underweight BMI<18.5 • Normal BMI 18.5-24.9 • Overweight BMI 25.0-29.9 • Obese BMI 30.0-34.9 Class I BMI 35.0-39.9 Class II • Extreme Obesity BMI >40 Class III

  4. Epidemiology of Obesity

  5. Epidemiology of pregnant population • In one 2007 Californian study (Kim et al) it was found that >40% of women are overweight or obese when initiating pregnancy • A 2006 study (Johnson et al) looking at a US database showed 25% incidence of obesity when initiating pregnancy • In a 1999 study (lu et al) • 25% of women >200 lbs at first PNV • 10% >250 lbs • 5% >300 lbs

  6. Risks of Obesity in General Population • CAD, HTN, hyperlipidemia • DM Type II • Obesity hypoventilation syndrome, OSA, Asthma • GERD • Fatty Liver, Cholelithiasis, NASH, Cirrhosis • Stress urinary incontinence • Venous stasis, DVTs, PEs • Hernias • Infection (cellulitis, post-op wound infections) • Depression • PCOS, infertility

  7. Risks of Obesity in Pregnancy • Increased miscarriages • GDM • GHTN, PreE • Prolonged hospitalization • UTIs • Dysfunctional Labor • Hemorrhage • Increased rates of C-sections • Perioperative Risks

  8. Fetal Risks • Preterm Deliveries • Post Term Pregnancy • Lower Apgar Scores • IUGR • Macrosomia & shoulder dystocia • NICU admissions • neonatal and childhood obesity • Congenital malformations (spina bifida, omphalocele, heart defects)

  9. Increased incidence of C/S • European prospective study with more than 200,000 deliveries a BMI >40 was associated with 4 times risk of C/S. Cedergren MI et al • Another study C/S for nonobese was 20.7%, compared with 33.8% for obese (BMI 30-34.9) and 50% for extremely obese (BMI>35) Wiess JL et al. • Increase in Emergent C-Sections. Poobalan AS et al. • Overwieght OR 1.53 • Obese (30-34.9) OR 2.26 • Extremely Obese (>35) OR 3.38

  10. Perioperative morbidities • Prolonged operative time • Increased Blood Loss • Fe in PNC • T&C • H/H before OR • Increased risk of thromboembolism • Thrombopyphylaxis • Aspiration/Failed intubation • Anesthetic Morbidities

  11. Anesthesia Considerations • 75% of all anesthesia-related maternal deaths happened in obese pts • Difficult placement of IV access • Difficult achieving endotracheal airway • Pts more quickly desaturate • Difficulty placing epidural/spinal • Pt can't flex back as well • More tissue to go through • Importance of prophylactic CSE • Aspiration Prophylaxis • Bicitra • Consider NPO in labor • Anesthesia Consult in Class III obesity in third trimester (Class C)

  12. Prophylactic antibiotics • Review of 66 trials showed prophylactic abx reduces risk of infection up to 75%. Smaill et. al (Level A) • Study with bariatric pts showed inadequate abx levels in obese pts receiving 2 g of ancef (Edmiston et al)

  13. Thromboembolic prophylaxis • One of the leading causes of maternal death • Occurs more frequently in obese pts • SCDs Pre and postoperatively (Level C) • If BMI>40 Unfractionated Heparin 5000-10000 u q 8-12 hrs • No well designed RTCs to assess risk reduction therefore recommendations is expert opinion (Level C)

  14. Importance of team approach • Appropriately trained OR staff • Surgical assistant(s) • Anesthesiology staff trained in fiberoptic intubation

  15. Equipment • Bariatric set • Alexis retractor • Vacuum • elastoplast tape or Montgomery straps

  16. What to do with the Pannus?

  17. Incision Choice • Lack of randomized control studies. • Vertical incision • 12 fold greater risk of wound complications compared to transverse • Rapid, Easy to extend • Transverse Incision • Low • warm moist area under pannus • thought to increase risk of infection • Cephalad retraction of pannus • May lead to cardiopulmonary comprimise • Perumbilical/Supraumbilical • Avoid button hole • Avoid using the umbilicus as a landmark • Joel-Cohen recommended • Pannulectomy if necessary

  18. Intraoperative Considerations • Self retaining retractor • Alexis retractor • Fundal pressure often difficult and limited • Have vacuum available

  19. Closure • 1 or 2 delayed absorbable monofilament suture on facia. • Fascial stitch should incorporate >1cm of facia and stitch interval no <1 cm apart • Consider Mass closure (Smead Jones Technique) • Subcutaneous Suture • In a 2004 metanalysis (Chelmow et al)34% decrease in risk of wound complications with subcutatneous sutures when subcutaneous tissue >2cm (Grade A) • Drains • No additional benefit (Grade A) • Staples vs subcuticular • Decreased incidence of postop wound exploration with staples (Grade C)

  20. Smead Jones Closure

  21. Post operative morbidities • 10 fold increase in post-operative endometritis • Higher rates of wound infection • Close inspection of wound • Consider removing staples after discharge in office esp with vertical incision • Increased risk of thromboembolism • Encourage early ambulation • Postpartum weight retention • Encourage breast feeding • Nutrition counseling • Consider bariatric consult • Higher rates of PP depression • 40% with Class III obesity • Higher rates of pregnancy with OCPs • Consider IUD

  22. Sources • Gunatilake RP, Perlow JH. Obesity and pregnancy: clinical management of the obese gravida. Am J Obstet Gynecol 2011;204:106-119. • Perlow, Jordan H. "Chapter 6: Obesity in the Obstetric Intensive Care Patient." Obstetric Intensive Care Manual. 3rd ed. New York: McGraw Hill, 2011. 61-72. Print. • Beattie PG, Rings TR, Hunter MF, Lake Y. Risk factors for wound infection following Cesarean Section. Aust N Z J Obstet Gynaecol. 1994;34:398-402 • http://www.cdc.gov/obesity/data/trends.html • Kim SY, Dietz PM, England L, Morrow B, Calligan WM, Trends in pre-pregnancy obesity in nine states, 1993-2003. Obesity (Silver Spring) 2007; 15:986-93 • Lu GC, Rouse DJ, Dubard M, Cliver S, Kimberlin D, hauth JC. The effect of the increasing prevalence of maternal obesity on perinatal morbidity. AM J obstet Gyneecol 2001;185:845-9 • Stothard KJ, Tennant PW, Bell R, Rankin J. Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. JAMA 2009;301:636-650. • Weiss JL, Malone FD, Emig D, et al. Obesity, obstetric complications and cesarean delivery rate: a population-based screening study. Am J Obstet Gynecol 2004;190:1091-1097. • Cedergren MI. Non-elective caesarean delivery due to ineffective uterine contractility or due to obstructed labour in relation to maternal body mass index. Eur J Obstet Gynecol Reprod Biol 2009;145:163-166. • Vallejo MC. Anesthetic management of the morbidly obese parturient. Curr Opin Anaesthesiol 2007;20:175-180. • Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for cesarean section. Cochrane Database Syst Rev 2002; CD000933. • Edmiston CE, Krepel C, Kelly H, et al. Perioperative antibiotic prophylaxis in the gastric bypass patient: do we achieve therapeutic levels? Surgery 2004;136:738-747. • Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ 3rd. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med 2005;143:697-706.

  23. Sources (cont) • Wall PD, Deucy EE, Glantz JC, Pressman EK. Vertical skin incisions and wound complications in the obese parturient. Obstet Gynecol 2003;102:952-956. • Hopkins MP, Shriner AM, Parker MG, Scott L. Panniculectomy at the time of gynecologic surgery in morbidly obese patients. Am J Obstet Gynecol 2000;182:1502-1505. • Ceydeli A, Rucinski J, Wise L. Finding the best abdominal closure: an evidence-based review of the literature. Curr Surg 2005;62:220-225. • Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis. Obstet Gynecol 2004;103:974-980. • Magann EF, Chauhan SP, Rodts-Palenik S, Bufkin L, Martin JN Jr, Morrison JC. Subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol 2002;186:1119-1123. • Ramsey PS, White AM, Guinn DA, et al. Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing cesarean delivery. Obstet Gynecol 2005;105:967-973. • Vesco KK, Dietz PM, Rizzo J, et al. Excessive gestational weight gain and postpartum weight retention among obese women. Obstet Gynecol 2009;114:1069-1075. • LaCoursiere DY, Barrett-Connor E, O'Hara MW, Hutton A, Varner MW. The association between prepregnancy obesity and screening positive for postpartum depression. BJOG 2010;117:1011-1018.

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